INTAKE FORM- Ruta Sawant

1. Demographic Details
Full name
Date of birth
Address
Contact details (phone number, email address)
Gender
Marital status
Occupation
2. Contact Details
Phone number
Email Id
3. Emergency Contact Details
Name of emergency contact
Relationship to the patient
Contact information
4. What issues are you currently facing ? (Answer in as much detail as possible)
State one concern you would like the therapy sessions to focus on with topmost
priority
State one negative thought you experience frequently
State one negative emotion you experience frequently
What behaviors do you engage in to deal with said emotions and thoughts?
Which event (or events) frequently trigger said thoughts?
5. About you
What are your biggest strengths?
What are your biggest weaknesses ?
How do you spend your free time?
Which activity brings you the greatest joy?
Which values (honesty, truthfulness, kindness etc) are the most important to you
(in yourself as well as in other people)?
6. Medical History
Are you currently under any psychiatric medication ? If yes, please state the name
and contact details of your psychiatrist
Are you currently under any treatment for any chronic illness? If yes, please state
the name and contact details of your physician.
Do you have any history of past psychiatric illness?
Do you have any history of psychiatric illness in your family?
Do you have any history of chronic physical illness running in your family?
Have you taken therapy previously? If yes, rate your satisfaction with the
experience on a scale of 1 to 5
Outside of therapy sessions, how many hours everyday are you willing to set
aside to work on your self-improvement goals?
What does “recovery” look like for you?
Confidentiality Agreement for Therapy Services
Patient Information

1. Patient Name: ______________________________________________________

2. Date of Birth: ______________________________________________________
3. Address: ______________________________________________________
4. Contact Information: ______________________________________________________
Therapist Information
My name is Ruta Sawant. I have completed my Masters in Applied Psychology (with
Clinical specialisation) from Vivekanand College of Arts, Science and Commerce. I am currently
pursuing training in CBT-REBT psychotherapy under Asira Chirmuley, Atha Psychotherapy.

Confidentiality Agreement

1. Purpose of Confidentiality: The purpose of this confidentiality agreement is to ensure

that all information shared between the patient and the therapist remains confidential
and is used solely for the purpose of providing therapy services.
2. Definition of Confidential Information: Confidential information includes, but is not
limited to, all information shared by the patient during therapy sessions, including verbal
and written communications, as well as any information obtained from third-party
sources.
3. Therapist's Obligations:
● The therapist will maintain the confidentiality of all information shared by the
patient.
● The therapist will not disclose any confidential information to any third party
without the patient's written consent, except as required by law or as necessary
to protect the patient or others from harm.
● The therapist will not use any confidential information for personal gain or
benefit.

Exceptions to Confidentiality:

● The therapist may disclose confidential information if required by law, such as in

response to a court order or subpoena.
● The therapist may disclose confidential information if the patient poses an
immediate threat to themselves or others.
● The therapist may disclose confidential information if the patient has given
written consent to disclose the information.
Patient's Rights:

● The patient has the right to request that the therapist disclose confidential
information to a third party.
● The patient has the right to request that the therapist limit the disclosure of
confidential information.
● The patient has the right to request that the therapist correct any inaccurate or
incomplete confidential information.

Therapist's Responsibilities:

● The therapist will maintain accurate and complete records of all therapy sessions
and confidential information.
● The therapist will ensure that all records are stored securely and are only
accessible to authorized personnel.
● The therapist will comply with all applicable laws and regulations regarding the
confidentiality of patient information.

Patient's Acknowledgement:

● By signing below, the patient acknowledges that they have read and understood
the terms of this confidentiality agreement.
● The patient acknowledges that they understand the therapist's obligations and
responsibilities regarding confidentiality.
● The patient acknowledges that they understand their rights and responsibilities
regarding confidentiality.

Signature of Patient: ______________________________________________________

Date: ______________________________________________________
Signature of Therapist: ______________________________________________________
Date: ______________________________________________________